Case of pancreatic carcinoma and other pancretaic tumors Dr Alekya katamreddy DMRD, resident sec DNB. JAYPEE HOSPITAL

1. DR ALEKYA KATAMREDDY
RESIDENT OF SEC DNB

2.  A 58yrs male patient presented with complaints
of
 Mild pain abdomen
 Loss of appetite to OPD.
OUTSIDE USG findings –
Chronic liver disease.
Altered pancretaic parenchymal echotexture
with peripancreatic fat stranding - ?pancreatitis
Advised to undergo CECT abdomen

3.  Plain, arterial and delayed phases of CT done
with oral neutral contrast .

8.  Plain scan revelaed ,
 There is atrophy of body and tail of the
pancreas
 Multiple small volume and prominent
peripancreatic and retroperitoneal
lymphnodes with surrounding mesnetric fat
stranding

9.  ARETRIAL PHASE:

25.  Post Iv contrast scan revealed
 There is hypoenhancing irregular soft tissue density
mass involving head, neck and body of pancreas ,
measuring appro 3.7 x 2.1cm. The mass is seen on
both sides of superior mesenetric vessels.
 Uncinate process is showing normal enhancement of
the pancreatic parenchyma which is spared
 The mass is showing extension into retropancreatic
region encasing the celiac artery, CHA, Proximal GDA,
splenic arteries completely and there is narrowing of
their lumen.
 There is mild soft tissue thickening seen surrounding
proximal segments of SMA and IMA also

26.  On delayed phase,
 There is invasion of portal vein ,its
confluence with SMV and invasion of
proximal splenic vein seen.
 In both the phases there is morethan 180
degrees encasement with invasion
 There is complete loss of fat plane with
medial wall of duodenum is noted suggestive
of infiltration

27.  All these findings suggestive of
 Pancreatic malignancy invading the medial
wall of duodenum with its extension into
retroperitoneum encasing the celiac,
common hepatic, gastro duodenal and
splenic arteries with soft tissue thickeing
around SMA, IMA , invasion of portal vein at
junction of SMV and splenic vein , prominent
regional nodes
 --- Suggestive of unresectable locally advanced
pancreatic adenocarcinoma.

28.  PDA is one of the leading causes of death in
GI malignancies
 Most common of pancreatic malignancies(
85-95%)
 Males >> female
 60-80 years
 Most common location in head of the
pancreas ( can be seen in the body and tail
of the pancreas)
 Patient presents with abdominal pain weight
loss and obstructive jaundice

29.  Initial imaging modality
 Appears as well defined focal hypoechoic or
heteroechoic lesion in head / body / tail of
the pancreas. Central necrosis also seen in
few cases
Dilated common bile duct and MPD ( Double
duct sign)
 Encasement of celiac trunk and superior
mesenteric vessels can be assessed
 Liver metastases
 Enlarged peripancreatic , periportal nodes

32.  Imaging study of choice
 Three-phase (noncontrast, arterial ( 35-40
seconds), and portal venous(90secs) CT scan with
coronal and 3 D reconstruction
 Lesion is hypoattenuating relative to the
normally enhancing pancreatic parenchyma in all
the phases
 Arterial phase is used to assess the encasement
of peripancreatic arteries
 Venous phase is optimal to evaluate the liver
metastasis and encasement or thrombosis of
venous structures and to see peripancreatic
planes
 Resectability can be predicted

33.  Indirect signs of pancreatic carcinoma
 1. Double duct sign
 2. Mass-effect or abnormal convex contour of
the pancreas
 3.Atrophic distal pancreatic parenchyma

43.  There are several additional imaging findings not
explicitly described in the NCCN guidelines criteria
defining resectability that are pertinent for surgical
planning and should be included in the radiology
template:
 1. The presence of tumor or bland venous thrombosis;
 2. Extension of tumor contact with the common hepatic
artery (CHA) to the level of the origins of right and left
hepatic arteries;
 3. Extension of tumor contact to first superior mesenteric
artery (SMA) branch and to most proximal draining vein
into SMV;
 4. Presence of increased hazy attenuation/stranding
contact with the vessel, particularly in patients who
received prior radiation therapy
 5. Arterial variants, in particular origin of the right hepatic
artery from the SMA.

44.  MRI is useful in doubtful cases of pancreatic
head mass in multidetector CT and for better
detection of small liver metastases ,omental,
peritoneal seedlings
 Small lesions in pancreas of size 1-2 cm are
better detected
 Lesions are hypointense on T1 images and
hypoenhancing on arterial phase, shows
progressive enhancement in delayed images
due to the fibrotic nature of the tumour

45.  On MRCP – double duct sign noted
 The characteristics of the pancreatic duct
dilation may suggest chronic pancreatitis or
pancreatic carcinoma as the cause.
 Dilated MPD is smooth or beaded with an
abrupt or gradual transition in caliber
 Irregularly dilated when associated with
chronic pancreatitis

46.  Small subcentimetre sized liver metastasis
 MRI may further delineate these lesions as
cysts, hemangiomas, or metastases, which
significantly influences patient workup and
prognosis
 More sensitive than CT for detecting
peritoneal enhancement and implants, which
are better appreciated in ascites

54.  Patients with PDA must be selected for first-line
surgery based on the likelihood of achieving
complete curative resection with negative
margins (R0); in doubtful cases and when the risk
of incomplete resection (R1 or R2) is high,
neoadjuvant chemotherapy and radiation
therapy should be performed.
 Excellent spatial resolution makes multidetector
CT the reference standard for initial PDA staging
 Particularly effective in assessing unresectability
criteria related to vascular spread.

55.  MR imaging has better contrast resolution
compared with multidetector CT , useful for
staging tumors with little or no visibility at
multidetector CT for detecting liver
metastases before decision to perform
resection surgery is made.
 Multidetector CT performs markedly less well
for evaluating the response to neoadjuvant
therapy; structural imaging carries a risk of
underestimating the treatment response.

56.  In patients undergoing neoadjuvant therapy,
a radiologic response, however limited, and
more specifically decreased vascular
involvement and/or tumor size, indicate high
likelihood of complete resection with
negative margins and therefore support
resection surgery.

57.  It is doubtful with a preoperative biliary
drainage is beneficial to the patient by ERCP
 Sometimes preoperative biliary drainage may
potential increased risk for post-operative
infections
 ENDOSCOPIC ULTRASOUND:
 is most sensitive diagnostic tool to evaluate
the lesion is less than 2 cm in size
 Useful to get biopsy in suspicious of focal
pancreatitis and pancreatic head mass

58.  1.Periampullary carcinoma (presence of
a bulging papilla sign may suggest the
diagnosis.)
 2. Focal pancreatitis
 3.Focal fatty infiltration in the head of the
pancreas ( By in and outphase MR imaging)
 4. Pancreatic metastatic lesion
 5. lymphoma

63.  FOCAL AUTOIMMUNE PANCREATITIS –
 Hypoattenuating and hypoenhancing
 Features that help supporting an
inflammatory process over malignancy :
Pancreatic calcifications
Pseudocysts
Duct penetrating sign

65.  PSUEDOCYST
 CYSTIC NEOPLASMS- SEROUS CYSTADENOMA
- MUCINOUS CYSTADENOMA
- IPMN
 SOLID WITH CYSTIC DEGENERATION- PANCREATIC ADENOCA
- CYSTIC ISLET CELL TUMOR
- METASTASIS
- CYSTIC TERATOMA
 RARE CYSTIC – SOLID PSEUDOPAPILLARY NEOPLASM
- ACINAR CELL CYSTADENO CA
- LYMPHANGIOMA
- HEMANGIOMA
- PARAGANGLIOMA
 TRUE EPITHELIAL CYSTS

66.  UNILOCULAR CYSTS
 MICROCYSTIC LESIONS
 MACROCYSTIC LESIONS
 CYSTS WITH SOLID COMPONENT

68.  PSEUDOCYST (MC)
 IPMN
 UNILOCULAR SEROUS CYSTADENOMA
 LYMPHOEPITHELIAL CYSTS- RARE
PSEUDOCYST
 Clinical history of pancreatitis
 Imaging finding like pancreatic inflammation
 Atrophy or calcification of pancreatic parenchma
 Dilatation of MPD & calculi in a thin walled pancreatic duct.
 Communication of pseudocyst with pancreatic duct – may be
seen in MRCP

70. SEROUS CYSTADENOMA (m.c)
 1-2% of exocrine pancreatic tumors.
 60 yrs- “grand mother lesions”
 Pain , wt loss, mass
 May be associated with VHL disease
 Large tumors , multiple cysts separated by fibrous
septa that radiate from centre forming a central
stellate star.
 USG : may appear as multilocular cyst or mixed solid &
cystic lesions, posterior acoustic enhancement.

71.  A fibrous central scar with or without a characteristic
stellate pattern of calcification is seen in 30% of cases
and, when demonstrated at CT or MR imaging is highly
specific and is considered to be virtually
pathognomonic for serous cystadenoma.
 CECT : hypervascular , enhancement of septations –
“swiss cheese” or “honeycombing”, “Spongy lesions”
 Arrangement of cysts around a central fibrous scar in a
sunburst pattern with coarse calcifications –
characteristic.

72.  Well- defined lesion showing low signal intensity onT1
and intermediate signal on T2 with “cluster of grapes”
appearance.
 Tumor septa seen as dark thin strands on T2
 Minimal enhancement & delayed enhancement of
central scar occasionally.
 ERCP :
CBD or pancreatic duct may be displaced , encased, or
obstructed by the tumor with no communication of
lesion with the MPD.

76.  Macrocystic lesions include multilocular cysts with
fewer compartments.The individual compartments are
>2 cm) larger than in serous cystadenomas.
 The cystic tumors in this category include
a) Mucinous cystic neoplasms and
b) IPMNs

77.  “MOTHER LESIONS” – AROUND 50 Yrs (M.C)
 female>> male
 rare & comprise of 2.5% of exocrine tumors
 body & tail – m.c sites
 they do not communicate with the pancreatic duct,
they can cause partial pancreatic ductal obstruction
USG :
 large ,well circumscribed multilocular cyst with thick
fibrous walls .
 presence of anechoic cavities & posterior acoustic
enhancement.
 liver – cystic metastasis( rare )

79.  Round to slightly lobulated mass i.e well encapsulated
with smooth external margins & near water attenuation
is seen
 Capsular or septal calcifications seen(10-25%)
 Internal surface may show nodularity representing
papillary projections
 Although peripheral eggshell calcification is not
frequently seen at CT, such a finding is specific for a
mucinous cystic neoplasm and is highly predictive of
malignancy.

81. Mucinous cystadenoma. Contrast-enhanced CT scan shows a cystic
mass (arrow) with rim calcification (arrowhead) in the tail of the
pancreas

83.  50 yrs, mother lesions
 Solitary(mc)
 Body & tail
 Peripheral calci+
 Tumor nodule
enhancement+
 High signal in cystic
areas suggestive of
old hemorrhage.
 60 yrs, grand mother
lesions
 Multiple,>6,
 Head of pancreas
 Central calcifications
 Septal enhancement+

84.  Intraductal papillary mucus producing neoplasms arising from
MPD or its main branches.
 Male > female
 60-80 yrs
 TYPES- a) MAIN DUCT TYPE
B) BRANCH DUCT TYPE
C) MIXED type(side br tumor extend into MPD)
 May present as abdominal mass, diarrhea, dm ,wt. Loss.
 IPMN represent spectrum of dysplasias ranging from simple
hyperplasia to carcinoma.
 Narrow neck at the cyst- duct junction on ct or mrcp

85.  Identification of a septated cyst that communicates
with the main pancreatic duct is highly suggestive of a
side-branch or mixed IPMN
 However, it is important to be aware that lack of
communication with the main pancreatic duct at
imaging does not exclude an IPMN.
 Currently, MRCP is considered the modality of choice
for demonstrating the morphologic features of the
cyst (including septa and mural nodules), establishing
the presence of communication between the cystic
lesion and the pancreatic duct, and evaluating the
extent of pancreatic ductal dilatation

86.  USG : Cystic mass, ductal dilatation or presence of
echogenic contents due to mucin
 Branch duct type lesion demonstrates a hypoechoic
mass with lobulated borders in uncinate process of
pancreatic head
 MRCP : Thick wall , solid mural nodules, diffuse main
duct dilatation > 10 mm, Intraductal filling defects,
bulging duodenal papilla, papillary projections suggest
malignancy.
 Vascular encasement, peripancreatic lymphadenopathy
& metastasis – confirms malignancy.
 Side branch lesions > 30 mm diameter- malignant.

87.  Because these lesions are considered premalignant,
surgical resection has been recommended.
 The occurrence of malignancy is significantly higher in
main duct and mixed IPMNs than in side-branch IPMNs
 Septated pancreatic cysts less than 3 cm in diameter
have generally low malignant potential.
 Cyst location may also be a factor in decision making,
since a small lesion located in the tail of the pancreas
may require a relatively less aggressive distal
pancreatectomy, whereas a lesion located in the
pancreatic head requires the far more complex
Whipple procedure.

90.  Cysts with a solid component may be either unilocular or
multilocular.
 True cystic tumors -Mucinous cystic neoplasms,
- IPMNs
- Solid pancreatic neoplasms with a
cystic component or cystic
degeneration i.e
. Islet cell Tumor,
. Solid pseudopapillary tumor,
. Adenocarcinoma of the pancreas &
. Metastasis

91.  Neuroendocrine tumors of pancreas.
 1) functioning –
Insulinoma(small, <2cm)
gastrinoma(small, mutiple)
glucagonomas(large)
vipoma
somatostatinoma(head, > 3cm)
2) non functioning(large size)
 Multicentric
 Body & tail – m.c harmonally active tumors

92.  Usg : well circumscribed, smooth margins
round- oval , hypoechoic
 Ct : small lesions are homogenous
large are heterogenous with cystic areas
hypervascular rim.
 Have a distinct capsule,
 Peak contrast enhancement in early arterial phase(25-
35 sec) rather than late arterial phase(35-45sec)
 MRI : T1 - hypo
T2 – Hyper
T1C+(Gd) – hyperintense (Hypervascular)

94.  RARE, LOW GRADE MALIGNANCIES
 PRGESTERONE RECEPTORS + > 90%
 YOUNG FEMALES “ DAUGHTER LESION “
 HEAD OR TAIL- M.C
IMAGING :
 USG : LARGE WELL MARGINATED, ENCAPSULATED,
PREDOMINENTLY CYSTIC COMPONENT,
HEMORRHAGE, NECROSIS & CALCIFICATIONS
 CT : VARIABLE ATTENUATION WITH THICK ENHANCING
CAPSULE, PERIPHERAL CALCATIONS
 MRI : FIBROUS CAPSULE WHICH IS HYPOINTENSE ON BOTH
T1 & T2

96.  MR imaging with MR cholangiopancreatography is
considered superior to single-section helical CT for the
detection of small mural nodules.
 A mural nodule is seen as an area of low signal intensity
on T2-weighted MR images, and contrast material
enhancement following the injection of gadopentetate
dimeglumine is diagnostic for its presence.